Endocrine
Perspective
by
GEOFFREY P. REDMOND, M.D.
Past Endocrine Columns
Dear Dr. Redmond: There has been a lot
of talk in the media recently about a big study on hormone replacement therapy
in the United States that had to be cancelled because they found out there are
risks for women who take hormones. I am interested to hear what you think of
this.
The news story you refer to was about a large trial
organized by the Women’s Health Initiative (WHI), sponsored by the National
Heart, Lung, and Blood Institute (NHLBI), which found some increased risks in
women taking an estrogen/progestin combination. This has received enormous play
in the media, which carried headlines like: “The End of the Era of Estrogen,” or
“HRT Does More Harm than Good.”
Journalists know that scaring people sells. Fear however does not help people
make personal healthcare decisions. It would be hard to find anywhere a woman of
menopausal age who has not been confused or distressed by these stories. My goal
in this column is to present the issues as objectively as possible, as an aid to
individual decision-making. There are both good and bad things about estrogen
and I will cover both. I can’t cover everything in this space however so each
patient needs to consult with her own physician.
Unfortunately the issues regarding HRT have been cast in black and white terms.
There are two kinds of possible benefit to this therapy: better long-term
health, and improved quality of life. The medical profession is often
uncomfortable dealing with quality of life issues and so has emphasized the
supposed long-term health benefits, particularly protection from heart disease
and osteoporosis.
What has been left out is how women feel at this phase of their lives. Sad to
say, the healthcare establishment has not always considered the matter of women
“feeling well” as worthy of its attention. In my view, medicine is more than
just something to keep people alive; it is also keeping them feeling well and
able to enjoy their lives. I think both long-term health and immediate
quality of life are important.
The discontinued group of the WHI study did have increases in certain health
risks. But they also had decreases in some other risks, and the results were
suspected from earlier studies.
The study found slight increases in the risk of invasive breast cancer, heart
attacks, stroke and blood clots in the lungs. The risk of each was less than one
in a thousand per year. There was a decreased risk of colon cancer, and hip
fractures. Other studies have shown a decreased risk of Alzheimer’s.
The risk of breast cancer did not start to rise until after the fourth year (a
finding consistent with other studies), which means that women can try HRT for a
while to see how much it helps without affecting their breast cancer risk.
Earlier studies have found that breast cancer in women on estrogen is usually
more favorable in prognosis, so the death rate is probably not higher. Still, no
one wants to have a breast removed. Few know that drinking an average of two
glasses of wine a night increases breast cancer risk as much as does taking
estrogen. Yet we do not see magazines announcing the end of the wine era.
The women in the study were not on estrogen alone but on Prempro, which is a
combination of conjugated equine (horse) estrogens (Premarin), and a synthetic
form of progesterone (Provera, generic name medroxyprogesterone acetate or MPA).
Another group within the study which is on estrogen-only has so far not been
reported to have increased risk. This group continues in the study and is due to
be completed in March 2005 . It is possible that the problem is not the estrogen
but the synthetic progesterone. We’ll know better when this second trial is
finished.
My own view is that for women who have decided that they do want estrogen,
estradiol in patch form and natural progesterone come closest to supplying the
hormones in the way the ovary does. Does this mean that there is less risk with
this regimen? We don’t know yet; but until more studies have been done, this
approach seems to me to make the most sense.
Women contemplating HRT should discuss their decision with a knowledgeable and
interested physician. Some women clearly do not have any reason to take
estrogen: If a woman is feeling great, sex is comfortable, and her skin and hair
is normal, there is no indication for taking estrogen unless circumstances
change.
The real issue involved in the HRT decision is this: Does the individual need
HRT to feel well and function at the level they want? If the answer is no, then
there is no reason to take HRT. On the other hand, if the individual feels
miserable off HRT, then taking it may at least be considered. The study told us
something that many of us thought anyway: HRT is for some women, not all.
The situation is not fair. No one should have to make a decision between
well-being and future risks, however small. Unfortunately, it seems to come down
to this.
Here is a vital point to remember: Starting estrogen is not a life-long
commitment. Risks rise slowly, so the therapy can be tried for a few months to
see if it really makes a difference. A woman can change her mind at any time. A
good way to do this is to reassess the situation at six-month intervals.
Past
Endocrine Columns
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